Alcohol abuse during pregnancy is a serious problem. Research suggests that 1) abstinence is the optimum strategy, but any decrease in alcohol consumption during pregnancy is beneficial; 2) drinkers underestimate their ethanol consumption; 3) supportive counseling is better than impersonal or purely medical approaches; and 4) in the context of a supportive environment, desire for a healthy baby is a powerful motivator. We propose to test a simple intervention in a mature managed care organization. The Kaiser Permanente Medical Care Program has implemented a substance abuse harm reduction program known as Early Start in 15 obstetrics clinics in California. We propose to enhance Early Start by helping women recognize how much alcohol they consume. We will use sample vessels, photographs of similar containers, and a simple software application that permits a counselor to show a pregnant woman what the Quantity and Frequency of her ethanol consumption actually is. Our Specific Aims are to test two hypotheses. HYPOTHESIS 1: Eligible women who abuse alcohol and who are provided with intensive education and careful quantification of their ethanol consumption (Group 1, Early Start Plus, or intervention arm) will have better perinatal outcomes (e.g., lower rates of neonatal assisted ventilation) than eligible women who simply receive confidential counseling (Group 2, Early Start, or "usual care" arm). Women in these two groups will have significantly better perinatal outcomes than those who receive no counseling at all (Group 3, comparison arm). HYPOTHESIS 2: Substance abusing women in Group 1 (Early Start Plus) will have higher rates of abstinence or cutting down on their drinking than those in Group 2 (Early Start). Women in these two groups will have significantly higher rates of abstinence or cutting down on their drinking than those who receive no counseling at all (Group 3, comparison arm). These hypotheses will be tested by randomizing 15 Early Start clinics to either the intervention or usual care arms. Each arm will consist of 7-8 obstetrics clinics. In addition, 2 KPMCP clinics where Early Start is not implemented will serve as comparison sites. We anticipate retaining 600 women in each of the 3 treatment arms during a 36 month period. We will then compare rates of a combined perinatal outcome measure (which includes mortality and morbidity) as well as decreases in maternal alcohol intake in the intervention, "usual care," and comparison arms. Our long term goals are to increase patient, provider, and policymaker awareness of the importance of alcohol abuse in pregnancy and to demonstrate the applicability of a simple, targeted intervention in a managed care organization.